Ethical Question About Pacemaker
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Hi all! I have an ethical/end of life question for you. I had a patient who had a pacemaker placed in the 90s as well as an AVR a couple years previous to this visit. The patient was a young patient... Read More

What makes you think that hospice doesn't get that patients at end of life are allowed to self determine?

tewdles, in an earlier post on this thread you stated that to avoid an ethical conflict of interest, hospice will not participate in removing the pacemaker, and leaves the decision up to the family. If the patient has expressed a wish for a natural death and the patient/family has not thought of the pacemaker and its action and broached the subject of turning it off with the doctor, then the pacemaker will continue to work. If I have understood correctly the position of hospice on pacemakers, as expressed by you here, I too feel uncomfortable. According to you, turning off a defibrillator is fine, but not a pacemaker? How does that make sense? To my mind, as someone with a family member who may one day require a pacemaker, and who has expressed a wish for no artificial efforts to prolong life, this is chilling information to learn.

I quote from another of your posts below:

"We rarely have to DC pacers in hospice...defibrillators are quite a different matter as has been addressed in earlier comments."

"Most of the time, our patients will die regardless of pacing and it is typically not necessary to DC the device."

"Some hospices consider discontinuation of a pacemaker as an action intended to shorten the lifespan and refuse to participate..."

tewdles, in an earlier post on this thread you stated that to avoid an ethical conflict of interest, hospice will not participate in removing the pacemaker, and leaves the decision up to the family. If the patient has expressed a wish for a natural death and the patient/family has not thought of the pacemaker and its action and broached the subject of turning it off with the doctor, then the pacemaker will continue to work. If I have understood correctly the position of hospice on pacemakers, as expressed by you here, I too feel uncomfortable. According to you, turning off a defibrillator is fine, but not a pacemaker? How does that make sense? To my mind, as someone with a family member who may one day require a pacemaker, and who has expressed a wish for no artificial efforts to prolong life, this is chilling information to learn.

I quote from another of your posts below:

"We rarely have to DC pacers in hospice...defibrillators are quite a different matter as has been addressed in earlier comments."

"Most of the time, our patients will die regardless of pacing and it is typically not necessary to DC the device."

"Some hospices consider discontinuation of a pacemaker as an action intended to shorten the lifespan and refuse to participate..."

Correct...most hospice patients will die without incidence with a fully functional pacemaker in place.
If the patient or family want it DCd they may have it DCd and hospice will include it in the POC.
Hospice would generally NOT recommend DC of the pacemaker. If my daughter was on hospice and you DCd her pacemaker you would precipitate her death. That may be the goal of the patient or family but causing death is NEVER a goal of hospice.
Our actions and recommendations should never have the intent to hasten death or shorten life, thus the DC would not be our recommendation.

Defibrillators activate in response to an event and provide a very uncomfortable intervention to preserve life. That is not compatible with a hospice philosophy for comfort and dignity at EOL, so we recommend DCing the device. RECOMMEND.

In each of these instances, the patient and family decide...period...not the hospice.

Hospice is ALL ABOUT patients self actualizing at end of life. We provide support, education, guidance, and expertise in symptom management.

Correct...most hospice patients will die without incidence with a fully functional pacemaker in place.
If the patient or family want it DCd they may have it DCd and hospice will include it in the POC.
Hospice would generally NOT recommend DC of the pacemaker. If my daughter was on hospice and you DCd her pacemaker you would precipitate her death. That may be the goal of the patient or family but causing death is NEVER a goal of hospice.
Our actions and recommendations should never have the intent to hasten death or shorten life, thus the DC would not be our recommendation.

Defibrillators activate in response to an event and provide a very uncomfortable intervention to preserve life. That is not compatible with a hospice philosophy for comfort and dignity at EOL, so we recommend DCing the device. RECOMMEND.

In each of these instances, the patient and family decide...period...not the hospice.

Hospice is ALL ABOUT patients self actualizing at end of life. We provide support, education, guidance, and expertise in symptom management.

tewdles,

I appreciate your reply.

When you say most hospice patients will die without incidence with a fully functional pacemaker in place, I am not sure what you mean by "without incidence." If the patient's goal is to die a natural death, both the pacemaker and defibrillator will prevent the patient dying a natural death. The pacemaker will prolong the patient's life, as will the defibrillator. Both are artificial mechanical devices. Turning the defibrillator off will allow the person to die a natural death even though the patient's death is hastened in the process. Turning the pacemaker off will allow a person to die a natural death even though the patient's death is hastened in the process. These are natural deaths. When the artificial mechanical devices are removed, the patient dies a natural death, not an artificially hastened death. So it makes no sense to me to say in the context of turning off a pacemaker that causing death is NEVER a goal of hospice, for to turn off a pacemaker is not to cause death, any more than to turn off a defibrillator is. Turning them off merely allows a natural death to take place.

I am concerned with the possibility that the patient and family may be told at an extremely stressful and painful time, by hospice, that turning off a pacemaker would not be hospice's recommendation, because, if I have understood you correctly, hospice's notion is that turning off a pacemaker = hastening death. How does a patient/family reconcile that hospice recommends turning off a defibrillator but not a pacemaker? I hope hospice directs the patient and their family to discuss the issue of turning off the pacemaker with their doctor.

The evidence simply does not support the concern that the pacemaker will prolong the life of the patient. This would certainly be true for a pacer dependent patient, such as my daughter, but the vast majority of patients do not fall into that category. Even children with very young hearts die with pacemakers functioning.

The difference between a functioning defibrillator and a functioning pacemaker are huge in the hospice setting. The defibrillator will activate, it will hurt, and it will attempt to prolong life when the patient is dying. The pacer, not so much...it will continue to fire and attempt to pace cardiac tissue that will not respond. It is not uncomfortable and it is not effective in preventing death.

Patients can and should speak with their PCPs regarding these devices when they have life limiting illnesses

The evidence simply does not support the concern that the pacemaker will prolong the life of the patient. This would certainly be true for a pacer dependent patient, such as my daughter, but the vast majority of patients do not fall into that category. Even children with very young hearts die with pacemakers functioning.

The difference between a functioning defibrillator and a functioning pacemaker are huge in the hospice setting. The defibrillator will activate, it will hurt, and it will attempt to prolong life when the patient is dying. The pacer, not so much...it will continue to fire and attempt to pace cardiac tissue that will not respond. It is not uncomfortable and it is not effective in preventing death.

Patients can and should speak with their PCPs regarding these devices when they have life limiting illnesses

tewdles, the evidence provided by the OP and other nurses on this thread is that the pacemaker was helping to prolong the patient's life, and that turning the pacemaker off allowed their patients to die without their lives being artificially prolonged. That is enough evidence for me. Do you not find these nurses accounts credible? One nurse at least is an ICU nurse I believe.

I don't know what their experiences are, I only know what I know about end of life as it relates to pacemakers.
I know that I work with people at end of life exclusively.
I know that I have been doing this for quite sometime, in more than one state, and for more than one agency.
I know that the literature supports what I am telling you.
I know that my anecdotal experience in critical care, ED, acute care transport, and hospice all supports what I am stating.

People can have their pacemakers DCd if they want. It is typically not necessary and does not change the trajectory of decline and death in hospice. Yes, there will always be outliers...especially in health care and medicine. Perhaps that (the pacer prolongs the life and delays the death) would be true for some but it is clearly not true for the vast majority.

The hospice intent in care is NEVER to hasten a death by action or inaction. Families may do as they choose and hospice will support them to the best of our ability as long as they are not breaking laws (ie: actively causing the death of their loved one). I have never worked for a hospice medical director who recommended DC of a simple pacemaker when a patient has elected their hospice benefit...never, it just is typically NOT an issue at time of death. On the other hand, EVERY medical director I have worked with asks immediately if the pacer has a defibrillator component and then recommends STAT DC of that feature if it has not already been addressed by the PCP and patient.

I am sorry if this difference of professional opinion is troubling for you. I am not intending to be argumentative or irritating.

tewdles, I appreciate hearing your thoughts and experience. I also appreciate you telling me about hospice. No, I didn't think you were intentionally being argumentative, and it was not my intention to be either. Thank you for taking the time to reply as thoroughly as you did, and for posting the links to the journals.

you did the right thing. because that is the patient wish. according to my professor in college. never incorporate too much emotion on the things you do specially on the hospital. but be sensitive enough to their needs.